Inspections
The most recent comprehensive inspection of RAFIKIHOMES UCGP LLC occurred on March 22, 2023, 31 violations of state standards were cited.
Findings
(May include findings from previous inspections)
Health Code
| Date | Corrected | State Violation Cited |
|---|---|---|
| 3/22/2023 | 4/30/2023 | The facility failed to list each resident's medications on a specific medication profile record documenting the required medication details (e.g., strength and dosage). |
| 3/22/2023 | 4/30/2023 | The facility failed to provide a locked area for all medications. |
| 3/22/2023 | 4/30/2023 | The facility failed to train all staff in emergency and evacuation procedures prior to their assuming any job responsibilities. |
| 3/22/2023 | 4/30/2023 | The facility failed to ensure that specific on-the-job training required for attendants in this type facility was completed in the required timeframe. |
| 3/22/2023 | 4/30/2023 | The facility failed to ensure that a licensed person or a trained, authorized, and delegated person administered medications according to physician's orders. |
| 3/22/2023 | 4/30/2023 | The facility failed to ensure doors in the facility met the referenced codes and standards. |
| 3/22/2023 | 4/30/2023 | The facility failed to inspect, test, and maintain fire alarm system components. |
| 3/22/2023 | 4/30/2023 | The facility failed to have a complete fire safety plan for the protection of everyone in the facility in the event of a fire. |
| 3/22/2023 | 4/30/2023 | The facility inappropriately admitted or retained residents whose needs could not be met. |
| 3/22/2023 | 4/30/2023 | The facility failed to train staff in the use of fire extinguishers, failed to inspect and maintain fire extinguishers, and failed to keep records of inspection and maintenance of fire extinguishers. |
| 3/22/2023 | 4/30/2023 | The facility failed to keep current and complete personnel records |
| 3/22/2023 | 4/30/2023 | The facility failed to ensure that each resident had a health examination by a physician performed within the required timeframe. |
| 3/22/2023 | 4/15/2023 | The facility failed to either assess a resident or to develop, approve, sign, or follow a service plan within the allowable time. |
| 3/22/2023 | 4/1/2023 | The facility failed to ensure that menus were prepared to provide a balanced and nutritious diet, that food was palatable and varied, or that menus were planned one week in advance, followed, posted and kept for 30-days, with variations documented. |
| 3/22/2023 | 4/30/2023 | The facility failed to procure food from acceptable sources, or failed to handle food, subject to spoilage, as required. |
| 3/22/2023 | 4/30/2023 | The facility failed to ensure that resident records included the required information and documentation. |
| 3/22/2023 | 4/30/2023 | The provider did not make all facility books, records, and documents accessible to HHSC staff upon request. |
Life Safety Code
| Date | Corrected | State Violation Cited |
|---|---|---|
| 9/8/2021 | Pending | |
| 9/8/2021 | 10/30/2021 | The facility failed to obtain an inspection by the fire marshal every year and to keep documentation showing the outcome of the last inspection. |
| 9/8/2021 | 10/30/2021 | The facility failed to conduct required fire drills and document fire drills on the required form. |
| 9/8/2021 | 10/30/2021 | The facility failed to inspect, test, and maintain fire sprinkler system components. |
| 9/8/2021 | 10/30/2021 | The facility failed to ensure an attic was not used for storage. |
| 9/8/2021 | 9/30/2021 | The facility failed to ensure equipment could be accessed to the facility could inspect, test, and service the equipment. |
| 9/8/2021 | 10/30/2021 | The facility failed to ensure doors in the facility met the referenced codes and standards. |
| 9/8/2021 | 10/30/2021 | The facility failed to provide a manual fire alarm system that met the referenced codes and standards. |
| 9/8/2021 | 10/30/2021 | The facility failed to provide portable fire extinguishers that met the referenced codes and standards. |
| 9/8/2021 | 10/30/2021 | The facility failed to conduct and document a risk assessment for potential emergencies or disasters. |
| 9/8/2021 | 10/30/2021 | The facility failed to review the plan at least annually to reflect changes in information, within 30 days following a disaster, within 30 days after a drill, and within 30 days after a change in rule or policy. |
| 9/8/2021 | 10/30/2021 | The facility failed to include a section addressing sheltering arrangements in the emergency preparedness and response plan. |
| 9/8/2021 | 10/30/2021 | The facility failed to include a section addressing evacuation in the emergency preparedness and response plan. |
| 9/8/2021 | 10/30/2021 | The facility failed to provide the required emergency preparedness and response plan training and conduct drills. |
Enforcement Actions
Date of Action
8/22/2023
Action Taken
Administrative Penalty
Final Assessed Amount
$4000.00
Related Violations
| TAC | State Violation Cited |
|---|---|
| 553.123(c) | The facility failed to ensure doors in the facility met the referenced codes and standards. |
| 553.104(c) | The facility failed to have a complete fire safety plan for the protection of everyone in the facility in the event of a fire. |